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ELIGIBILITY
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Eligibility
Info: |
Patient must be a US resident.
Patient must meet program income requirements which may vary by product and household size.
Patient must have limited or no private or public prescription coverage. |
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Couple |
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% FPL |
Income at or below: |
Not
Published |
Medical expenses
can be deducted from reported income: |
Not
Published |
Social security requested on form: |
Yes |
US citizenship/residency specified:
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Yes |
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APPLICATION |
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Attachments
Required: |
Financial
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Physician
License #
Required: |
Both DEA and State
NPI
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Prescriber
Signature
Allowed: |
Physician
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Application
may be
faxed: |
Yes
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Eligibility
determination
letter sent: |
Provider
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MEDICATION |
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Receives: |
Medication
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Shipped To: |
Patient
Note: For Clozaril, Focalin XR and Ritalin LA the patient will receive a pharmacy card.
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Quantity in
Shipment: |
Not Published
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Delivery Time: |
0-1 week
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Re-application
Policy: |
New application every 12 months
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Refill Policy: |
Contact program for refills |
Other Information: |
Additional products may be available. Please contact the program for a complete product listing. www.pap.novartis.com |
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